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Tuesday, April 26, 2011

You're the doctor

Julie, of the fabulous blog Races Like a Girl, was dealing with an injury last fall and in this post offered a prize to anyone who could accurately diagnose her problem. She was, of course, receiving the appropriate medical diagnostic tests for the issue as well. I ended up being the grand prize winner having guessed stress fracture of the femur or pelvis before anyone else did, but I was shocked at how many people guessed correctly! My prize was a Barnes and Noble gift card, which, ironically, I used to buy ebooks for my iPad to read while I was rehabilitating my own injuries after the Athens Marathon.

So, I am enlisting your help, dear readers, to figure out what causes my left leg to tighten up about 30-40 minutes into each and every run. I have been treating my IT band (stretching, rolling, icing, time off from running, strength training, acupuncture, active release therapy) for the last month and am now quite sure that, while the pain I feel is coming in part from an irritated IT band, this is a symptom and not the cause. I am looking for the root cause here, so I can treat it and get back to running longer than 40 minutes at a time.

During my run, a typical progression goes something like this:

the first 3 miles feel awesome;

some tension just above and to the outside of my kneecap appears or the lower part of the outside of my leg tightens up;

that tension goes away, and I might feel some pulling or tightness below my kneecap;

the outside of my upper leg eventually starts to feel a little weak or achy and;

finally, I get a fairly persistent ache in the outside of my kneecap where the IT band rubs over the end of the femur. Sometimes this is felt behind my knee and even into my calf. This comes and goes later in the run and does not become worse the longer I run beyond 45 minutes, though I haven't done too many runs over 45 minutes. Oddly enough, when I put direct pressure on the point where I feel this tightness, it does not hurt at all. During the latter parts of many runs, I have felt as though my lower left leg is a peg leg, with no ability to push off at all.

I have been doing everything right according to Dr. Lau: stretching every day after my run, rolling out my legs each night, regular strength exercises for my core and glutes. The problem has not gotten any better or any worse over the last month despite all of this treatment. I had a fantastic run last Thursday night, running 6 miles with 30 minutes at 6:30 pace. I felt awesome the entire run, with no tightness at all in my leg. The next morning, I tried to jog just a few miles and felt the tightness within the first 15 minutes. So, Coach T decided it was time to try some cross training over the weekend. I biked and pool ran for three days and did not run a step on land. I ran today to see if anything had changed, and I still felt that insidious tightness off and on during my 8 mile run. It came on, you guessed it, after 30 minutes of running. It's not a run-stopping tightness at this point--so, no sharp pain. It's just there, and I am afraid to push it.

I was traveling for work last week and had to run on the treadmill in the hotel gym. I had my iPhone with me and decided to see if I could get some video footage of myself running. It actually turned out pretty well. I have been carefully analyzing these videos, and I see lots of things wrong with my form, of course. But what I really want to know is if any of you see clues that may indicate what is causing this leg tightness. I'm hoping something will jump out at one of you and that you will add your diagnosis in the comment section below. The quality needed to be lowered so that it wouldn't take forever for you to download, but I think you can still make out the important things. I left the sound unedited so you can hear my feet thudding on the treadmill in a Godzilla versus Mothra sort of way.

If you have trouble viewing the embedded video here, I've also loaded it on YouTube. I will say that I was treated after my morning run today (I won't disclose what part of me was treated since that might give something away) and am hopeful that the adjustment will help. Fire away!

17 comments:

I had the same, weird peg legged-feeling in my right lower leg during about 50% of my runs during my pregnancy. I woould also get very fatigued shin muscles in the same leg, to an extent where I felt like I could barely flex my foot to lift if off the ground. Do you feel that too? So, based on this my guess is you are with child. ;)

Sorry I could not be of any better help, but I really do love your blog!

I was going to suggest leg-length discrepancy, but Michelle beat me to it...

The other thing that I noticed (I am sure you did too) is that your left foot kicks lower than your right, suggesting that you're favoring one leg. Curiously, during the slow motion it seemed that you were really pounding that left leg.

Oh Boy, Jenny. I certainly hope that's not the case! The shin muscles on the left leg do get slightly fatigued. I notice it when I do my ankle rolls after my run and rolling to the outside on the left is just excruciating. I notice the same thing about barely being able to flex the foot.

Michelle, I have had the length of my legs checked and they are pretty close to the same. Thanks for the tip.

QS, Yes! The left leg is taking a pounding. Right now, the best explanation I've found for that (a lot of the diagnostics are happening via Facebook) is that the left ankle is tight which is keeping the left foot from being able to fully dorsiflex. So, it isn't able to supinate properly and that puts an extra load on the entire leg (a real doctor came up with that!). I was treated for just that issue yesterday, and will run later today to see if it is any better. Just walking around, I can feel a difference. I've been peg-legging even while walking!

have you had the strength of both legs analyzed and compared to each other? maybe you have a leg strength discrepancy which is causing you to over use one side or compensate more with one side. it could be one hamstring is stronger or one quad. you could easily do that yourself by going to the gym and doing the hamstring curl with each leg isolated and then the quad machine with each leg isolated and see if one can clearly lift more then the other after a series of 10 reps.

tmeat, Good thought. I sort of did that. Dr. Lau asked me to test the strength of my legs/glutes by having someone press down on my leg while I tried to lift it off the ground while laying on my side. My left leg is slightly stronger than my right, which doesn't really match up with what is happening if it were a strength problem. The bottom line for that test was that the person (a 180 lb. guy) could barely move either leg as I resisted, so I don't have an issue with glute strength like many runners with IT band issues have. That's when he started focusing on my ankle/foot.

We probably all have some discrepancy with strength and flexibility on one side or the other because one side is usually dominant. For me, my left always has been and probably always will be tighter than the right. I think that, unless it's a huge difference and can be directly linked to the problem, it's probably best just to leave it alone and work both sides equally. Our bodies naturally compensate in subtle ways, and it seems like correcting the problem might cause more harm than good. This issue for me likely would not have been a problem had I maintained a good base of strength work over the last 6 months and not ramped up my training quickly.

Jaymee,Has anyone given any thought to your lumbar spine? As a PT I have seen a few runners with referred pain into the knee/leg from a disc bulge or nerve compression in the low back. I have also certainly seen runners take nearly a year to recover from ITB problems even when they do EVERYTHING right.I would be curious about referred weakness/peg leg from nerve compression in the low back, particularly L5 or S1....just my 2 cents!

A friend posted this link on my FB and told me to look (I coach two folks who'll be running with you in Houston, fates willing!).

I want to see you from the side. Are you sure you're not overstriding? From the front it looks like you might be but the camera angle makes that a wild guess. You probably aren't but if so, it's an easy cure.

Other thoughts. (1) does this occur on flat surfaces or the treadmill? This is a classic slant-running injury from always facing traffic.(2) You seem to have some odd motion in the left hip, though I only see it in the rear view photo, and it might be an artifact of camera angle. But I'd have a pro check your hip flexibility and see if you need some stretches. Just because the ITB feels weird in the knee doesn't mean that the tightness originates there.(3) I hate to say this one, and I think it's unlikely, but you should rule out meniscus. Tiny meniscus tears can masquerade as ITB problems. (The ITB tries to splint them.) This probably isn't it, but I've seen it happen, and they're hard as heck even for the docs to diagnose.)

i had similar symptoms and it turned out that i had a large GLUTE Strength imbalance. The lack of glute strength de-stabalized my hip which ended up rocking 'down' on each step thus irritating the IT band down near the knee and also causing hip pain. Dr. Lau also thought it was IT band issues but after months I eventually went to a sports medicine doc who found the glute strength issue. She perscribed TONS of glute/core exercises which helped within a few weeks. Curious--can you do a one-legged squat on the right leg? How about the left? Watch yourself in the mirror (or have a friend watch) and if you having significant more trouble squating/balancing on the leg that is giving you pain, i bet it is the glute/hip issue I had. Good luck!

Mrs. V. Thanks for the idea. It doesn't seems to be referred pain to me, but it is something I will have to think more about. I have had some pretty severe lower back tightness throughout this that has been greatly relieved through acupuncture treatment. Hmmm.

rocky wing, you will definitely get credit if it's one of those two:)

Rick, I appreciate your insight. I have some video footage of me running from the side embedded in a longer video on Youtube: http://www.youtube.com/watch?v=DIZrWGYlPPY&feature=BFp&list=WL343052CD2469C361&index=1 The footage starts around 30 seconds into the video and it goes by very quickly. I sure don't think I'm overstriding, but what do I know? I would think that I would have a slow turnover rate if I was an overstrider, and mine is around 180-190. I can rule out the meniscus issue I think since I had an MRI done on the knee a couple of months back and they found nothing wrong with it.

For Rick and K, I have been strengthening the glutes/core, stretching my entire body for 20 minutes per day and rolling out my legs and back every day for almost a month. My glute strength is pretty darn good right now. An 180 lb guy couldn't push either leg down when I lifted each off the ground while laying on my side holding it up. I still struggle with hip tightness, but I sure would think that a month of stretching would have started to pay off by now.

Still focusing on foot, calf and ankle tightness at this point, though I still had the same problems in tonight's run.

Jaymee, I can see a difference left to right in the slow-mo, but as to what's causing it... not sure.

From the rear, I see more movement in the left ankle and pronation (not as much movement in the right). I think it's that movement which is making your left knee 'collapse' inward upon landing (obvious from the front slow-mo) which could be straining the knee/itb.

A cure? Apart from an orthotic/arch support to limit the ankle roll... perhaps single leg hopping as a drill trying to get the left and right leg to feel the same in their movement. Small and larger hops 5 or 6 in a row each leg or alternating 3 right, 3 left etc. Also exercises to strengthen the inner lower quad might help.

Ah, Ewen said exactly what I was going to say. You pronate more on the left, which means your left knee turns inward, which means the muscles on that side have to work harder to keep things in line (Oh yes, I'm a professional, sorry if my extremely technical language is confusing... :p) Have you ever had a professional gait analysis?

I'll leave treatment options for wiser and more experienced people to discuss and just say that what worked for me - with admittedly a whole different set of problems, collapsed arches and major leg-length discrepancy - were core exercises, foot-strength exercises, barefoot running drills and other stuff to address strength/flexibility imbalances. Orthotics are ok, but for me they just led to a whole different set of problems eventually.

Further to what Heather said re barefoot running vrs orthotics, if you can do some barefoot running and drills that might be useful. Keith Bateman swears by barefoot running - he also coaches (not online), but it might be worthwhile to drop him a line and see if he'll take a look at the video - http://keithbatemancoaching.com/

Ewen, thanks for the tips and the link. I think you and Heather are on the right track with the foot issue. I have been focusing on glute and core strengthening for a few months now and have not seen a change, so it seems like working on the other end of the leg makes sense. What my chiro sees in that video (and knows from having worked on me for a few months) is that my soleus on the left is super tight and is keeping the left foot from dorsiflexing which then doesn't let the foot supinate properly when it hits the ground. This is why the leg collapses and the knee turns in and the IT band gets jacked.

Heather and Ewen, I am going to take your suggestions to heart and plan to start (very slowly) doing some foot strengthening as well as stretching exercises including barefoot strides and plyometrics. Coach T and I can do these in the back yard together!

jaymee, i don't know if you remember, but i discovered i had a leg strength imbalance several months ago. i also discovered that my foot strike was different on my right foot compared to my left and the right leg was working harder then the left. so the right leg was actually stronger then the left. anyway... leonard has recently had me pepper in running with minimalist shoes (i got some nike frees) and even barefoot running on the grass (which i hate due to my freaky grass phobia, but that's another story). what's more... he has me doing a few sets of drills a few times a week which specifically work on foot strike and also strengthening some core muscles. he was especially inspired to experiment with this minimalist thing after reading "born to run". even things like your arms can play a role. if one wrist is turning in a certain way or if your arms are doing slightly different things, it can alter what happens to your lower body. and maybe these subtle things don't matter when you run a little, but when you start doing 100 mile weeks and/or a lot of volume, these subtle things eventually take a toll... so they are worth looking at.